Healthcare Provider Details

I. General information

NPI: 1194437483
Provider Name (Legal Business Name): EDUCARE COLLABORATIVE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2022
Last Update Date: 12/19/2022
Certification Date: 12/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

152 SOUTHGATE BLVD
MCDONOUGH GA
30253-8035
US

IV. Provider business mailing address

152 SOUTHGATE BLVD
MCDONOUGH GA
30253-8035
US

V. Phone/Fax

Practice location:
  • Phone: 678-988-6835
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251300000X
TaxonomyLocal Education Agency (LEA)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number
License Number State

VIII. Authorized Official

Name: KAREN IRWIN-COPELAND
Title or Position: NURSE
Credential:
Phone: 678-988-6835